Effect of Lateral Internal Sphincterotomy on Postoperative Pain and Anal Continence After Hemorrhoidectomy: A Randomized Controlled Open-Label Trial

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

Fecal incontinence 1,2

Pain following hemorrhoidectomy is a distressing sequel to the procedure. Various methods have been used to alleviate post-hemorrhoidectomy pain; among these methods is the lateral internal sphincterotomy (LIS). This review aimed to analyze all studies that evaluated the impact of LIS on the outcome of excisional hemorrhoidectomy. Seventeen studies were included after organized search of the literature using electronic databases including PubMed/Medline and EMBASE. The studies included comprised 2180 patients with median age of 44years. Variables selected for the review comprised patients' characteristics, postoperative pain assessment, analgesic consumption, and complications as fecal incontinence (FI), urinary retention, and anal stenosis. Overall, 933 (42.7%) patients underwent LIS. Almost all studies assessing postoperative pain reported lower pain scores and less need for postoperative analgesia among patients who underwent LIS in comparison with patients who did not have LIS. Eleven of 13 studies that assessed continence state postoperatively reported higher rates of FI among patients who had LIS with a median rate of 7.7% versus 1.25% for patients who did not have LIS. Incidence of urinary retention after LIS ranged from 0 to 60%. Anal stenosis occurred in 0-14.5% of patients who had LIS versus 0-36.4% in patients without LIS. LIS effectively reduced postoperative pain and need for analgesics following excisional hemorrhoidectomy. LIS also managed to decrease incidence of postoperative urinary retention and anal stenosis significantly. The negative aspect of adding LIS to excisional hemorrhoidectomy was developing minor FI after surgery which was temporary in duration.

BACKGROUND: Anal fissure is defined as a superficial tear in the skin distal to the dentate line and is one of the leading causes of hospitalization among proctologic disorders. Anal fissures are initially managed by conservative treatments, but have limited efficacy and may need surgical interventions. OBJECTIVE: The current study aimed to compare the effectiveness of Conventional lateral internal Sphincterotomy (LIS) versus tailored LIS in terms of pain, bleeding and recurrent symptoms as outcomes. METHODOLOGY: The prospective cohort study was carried out at Muhammad Teaching Hospital, Peshawar, including n=196 participants, diagnosed with Chronic anal fissures, over the age of 18 years, through informed consent. Patients were assessed for pain, bleeding, and recurrent symptoms pre-operatively and post-operatively at one-month intervals of follow-up. RESULTS: The Mean age of the participants was 34.50±11.18 years, including 52 (26.5%) males and 144 (73.5%), operated with Conventional LIS 94 (48%), and tailored LIS 102 (52%). Post-operative pain was significantly reduced, P<0.001 in both groups, with no difference P=0.182, between interventions. For flatus incontinence Significant difference by Fisher’s exact test P=0.028 reported between interventions, with a relative risk RR= 0.204 (CI 0.045-0.923), 0.039 for tailored LIS. For faecal incontinence, Fisher's exact test P=0.011 was significant between groups, and RR=0.070 (CI 0.004-1.242), P=0.070 was insignificant. Faecal soiling P=0.108, recurrent symptoms P=0.152, post-operative constipation P=0.124, and pruritus P=0.030 did not report significant differences among treatment groups when conventional LIS was compared with tailored LIS. CONCLUSION: Conventional LIS and tailored LIS were both effective in post-operative pain and bleeding reduction. Tailored LIS helped reduce post-operative flatus and faecal incontinence. The study was limited by a short follow-up duration and insufficient consideration of patients’ medical histories and comorbidities. KEYWORDS: Anal fissures, Conventional lateral internal Sphincterotomy, Tailored lateral internal Sphincterotomy, LIS, faecal incontinence, flatus incontinence.

Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique. However, it may be associated with coexisting occult sphincter defects. Whether continence is related to the extent of sphincterotomy remains debatable. The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division. One hundred eight patients with chronic anal fissure were prospectively studied before and after lateral internal sphincterotomy. A questionnaire was completed for each patient before and after surgery with regard to any degree of fecal incontinence. Fecal incontinence severity index was assessed using the Cleveland Clinic Incontinence Score. The patients with preoperative perfect continence were randomized into two groups (46 patients in each group): Group 1 underwent traditional lateral internal sphincterotomy (up to the dentate line) and Group 2 were underwent a conservative internal anal sphincterotomy (up to the height of the fissure apex or just below it). Minor degrees of incontinence were present before surgery in 16 patients (14.8%). Results of the randomized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients (6.52 %) who did not have it before surgery. Five of the six (10.86%) were in Group 1 one (2.17%) was in Group 2 (p = 0.039). Persistent incontinence occurred in two in Group 1 (4.35%). All of them were females. All have had a history of one or more vaginal deliveries. A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy. Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon. Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing, but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex. Care should be exercised in female patients with a history of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.

BackgroundHemorrhoids are a common condition that presents with bleeding per rectum, pain at rest and defecation, mucosal discharge, and prolapse. Surgical hemorrhoidectomy is the treatment method of choice for Grade 3 and Grade 4 hemorrhoids. Hemorrhoidectomy is associated with postoperative pain and no single surgical technique has been proved to significantly reduce the pain. We analyzed in our study the effect of lateral internal sphincterotomy with hemorrhoidectomy on postoperative pain, anorectal function, and retention of urine after the Milligan and Morgan technique.MethodsThis randomized, prospective, and comparative study included 200 Grade 3 and Grade 4 hemorrhoids patients who were scheduled for surgical management. The patients were classified randomly into two groups with an equal number of participants: Group A underwent Milligan & Morgan open hemorrhoidectomy and Group B underwent lateral internal sphincterotomy (LIS) in addition to Milligan and Morgan open hemorrhoidectomy. Postoperative pain was recorded using the Visual Analog Scale (VAS) score for up to 48 hours. Postoperative bleeding, urinary retention, and bowel and gas incontinence were noted. Long-term follow-up at six and 24 months for anal stenosis, anal fissure, incontinence, and recurrence was also noted.ResultsPatients who underwent LIS showed a significant reduction in postoperative pain at 12 hours (p=0.0008*), 24 hours (p=0.000*), and 48 hours (p=0.003*); the time taken to request rescue analgesia was similar between the two groups (p=0.07). Side effects, such as postoperative bleeding and urinary retention, were significantly lower after LIS (p=0.001* and p=0.01*, respectively), and gas incontinence was significantly higher after LIS (p=0.002*). The long-term outcomes of anal fissure were significantly higher without LIS at six months (p=0.02*) and 24 months (p=0.04*) and those of anal stenosis were significantly higher without LIS at six months (p=0.04*).ConclusionsFrom our study, we conclude that postoperative pain, bleeding, and urinary retention were significantly lower after LIS, and gas incontinence was transient. The long-term outcomes, which included anal stenosis and anal fissure, were significantly lower after LIS. However, bowel and gas incontinence and recurrence were not altered. Therefore, we conclude that the addition of LIS to hemorrhoidectomy improves patient outcomes in terms of postoperative pain and anorectal function.

Background: The primary objective of this investigation was to evaluate the prevalence of fecal incontinence after surgery in individuals who underwent open lateral internal anal sphincterotomy up to the dentate line compared to those undergoing anal sphincterotomy (open internal) up to the height of the anal fissure. Methodology: This study was randomized and controlled and was carried out in Abbasi Shaheed Hospital, Karachi, at the department of surgery between February 2021 and July 2022. The study enrolled patients who were 15 years or older and presented to the outpatient department with chronic anal fissure, regardless of gender. Patients with concomitant anal disease, those with previous history of anorectal surgery & those with systemic neurological disease leading to fecal incontinence were excluded. Analysis of the collected data was performed using SPSS version 23. For quantitative variables, such as age, standard deviation and mean were calculated. Conversely, the qualitative variables, such as gender, location of anal fissure, Browning and Park's classification of incontinence, and final outcome(i.e. fecal incontinence at 5th postoperative day), were assessed using percentages and frequency. Results: In this study, 198 individuals who are chorincally suffering from anal fissure were identified and divided into two groups, Group A and B, each consisting of 99 patients. Group A underwent an open lateral internal anal sphincterotomy up to the level of the dentate line (referred to as the "dentate line group"), while Group B received an open lateral internal anal sphincterotomy up to the height of the fissure (known as the "height of fissure group").Fecal incontinence was assessed and compared between both groups on 5th postoperative day by using Browning and Park’s classification. The findings of this investigation indicated that open lateral anal sphincterotomy up to the level of the dentate line was associated with an 11.1% incidence of fecal incontinence, while a 3% incidence of fecal incontinence was observed in individuals who underwent anal sphincterotomy (lateral internal) up to the height of the anal fissure. Practical Implication: present study suggests that lateral internal anal sphincterotomy up to the height of anal fissure may be associated with a lower risk of fecal incontinence compared to the dentate line group. Conclusion: The data obtained from this study suggested that open anal sphincterotomy (lateral internal) up to the height of the anal fissure was linked to reduced incidence rates of postoperative fecal incontinence on the fifth day after surgery, as compared to open anal sphincterotomy (lateral internal) up to the level of the dentate line. Therefore, this modification should be used in future regularly in order to reduce this morbidity. Keywords: Fecal incontinence, Chronic Anal Fissure, Sphincterotomy.

Introduction: Anal fissure is one of the commonest and painful proctologic diseases encountered in routine clinical practice causing considerable morbidity and reduction in quality of life. There are medical and surgical treatment options for anal fissure. The chronic fissures behave more differently in that way they are more persistent and relapsing than the acute fissures which are self-healing.Aims and Objectives: To compare the outcomes of open lateral internal sphincterotomy and closed lateral internal sphincterotomy using cataract knife in terms of duration of surgery, postoperative pain, faecal and flatus incontinence, duration of hospital stay.Materials and Methods: In this prospective study, 100 patients admitted with Chronic Fissure in Ano were randomly divided into Group A {Open Lateral Internal Sphincterotomy} And Group B {Closed Lateral Internal Sphincterotomy Using Cataract Knife} with 50 patients in each group. Regular follow up was done at weekly intervals for four consecutive weeks and biweekly for subsequent 2months.Results: In our study most of the patients fall under the age group of 25 to 50 years. And out of 100 patients, 46patients were female and 54 were male patients. Duration of surgery, postoperative pain, fecal and flatus incontinence, duration of hospital stay were better among patients who underwent closed lateral sphincterotomy when compared with open lateral sphincterotomy patients group.Conclusion: In our study it was observed that GROUP B has better outcomes in terms of duration of surgery, postoperative pain, fecal and flatus incontinence, recurrence when compared with GROUP A patients. Thus the present study concludes that the closed lateral sphincterotomy using cataract knife should be used as the primary treatment of choice in the management of chronic fissure in ano.

Troublesome faecal incontinence following a lateral internal sphincterotomy (LIS) is often attributed to faulty surgical techniques: division of excessive amount of internal sphincter or inadvertent injury to the external sphincter. The aim of the present paper was to assess the anatomic and physiological factors that may contribute to faecal incontinence following a technically satisfactory lateral internal sphincterotomy by a group of colorectal specialists. Fourteen patients (nine women, five men; median age: 38 years; range: 23-52 years) who developed troublesome postoperative faecal incontinence were evaluated by clinical assessment, endoanal ultrasonography and anorectal physiological studies (manometry, pudendal nerve terminal motor latency) by two independent observers. The Cleveland Clinic continence score (0-20; 0, perfect continence; 20, complete incontinence) was used to quantify the severity of faecal incontinence. Fourteen continent subjects after a LIS (nine female patients, five male patients; median age: 36 years; range: 20-44 years) were also evaluated as 'continent' controls (continence score </= 4). In the incontinent group, the median postoperative Cleveland Clinic continence score was 9 (range: 6-13) compared with a preoperative score of 1 (range: 0-3). On assessment by endoanal ultrasonography the site of the internal sphincterotomy was clearly identified. There were additional coexisting defects, on endoanal ultrasonography, of the external anal sphincter in seven female patients, of the internal sphincter in two female and two male patients; and a defect of both the external and internal sphincters in a male patient who had had a prior fistulotomy. The pudendal nerve terminal motor latency (PNTML) was prolonged in two female patients on the side contralateral to the lateral internal sphincterotomy. In two of five male patients there was no evidence of any occult sphincter injuries. In the continent controls a defect of the distal portion of the external sphincter was noted in one female patient. None of the patients had a prolonged PNTML. The maximum voluntary contraction was significantly lower in the female subjects than in the female continent controls (92 mmHg vs 140 mmHg; P < 0.05), while the resting anal canal pressures and length of the high pressure zone were similar between the study subjects and the continent controls. Troublesome faecal incontinence after a satisfactorily performed lateral internal sphincterotomy is often associated with coexisting occult sphincter defects.

Objectives The aim of this study was to assess the efficiency of rubber band ligation (RBL) in the treatment of symptomatic hemorrhoids in hepatic patients, versus surgical hemorrhoidectomy. Operative (time and blood loss) and postoperative (pain, bleeding, analgesic requirement, urinary retention, discharge, stenosis, fecal incontinence, wound healing and patient satisfaction) outcomes were evaluated. Background The aim of this study was to compare the outcome of hemorrhoidectomy performed using RBL with surgical hemorrhoidectomy. Patients and methods Forty patients with liver disease and diagnosed with grade I, II, or III hemorrhoids were randomized equally to be subjected to either RBL (group A) or surgical conventional hemorrhoidectomy (group B). Operative details were recorded and patients recorded daily pain scores on a linear analog scale. Follow-up was carried out weekly for 2 months and monthly for 6 months to evaluate complications, return to normal activity, ongoing symptoms, and patient satisfaction. Results Intraoperative blood loss was lower in group A, with a mean of 1.2 ± 1.6 ml (range 0–5 ml) versus 22.2 ± 6.58 ml (range 15–35 ml) in group B (P = 0.0001). Operative time was shorter in group A, with a mean of 9.00 ± 2.449 min (range 5–12 min) versus 24.100 ± 3.669 min (range 20–30 min) in group B (P Conclusion RBL operation is recommended for the treatment of hemorrhoids in hepatic patients especially in the second and third stage, as it results in less blood loss, less postoperative pain, earlier wound healing, and earlier return to work.

Background: Fissure in ano is one of the commonest benign and painful proctologic condition encountered in surgical practice treated by conservative line of management. Lateral sphincterotomy is the ideal treatment option for chronic refractory fissure in ano. A newer modality segmental internal sphincterotomy shows good promise in terms of early resolution of symptoms, fissure healing and prevention of anal incontinence involving division of the internal sphincter at two different levels.Methods: In comparative nonrandomized trial patients with chronic fissure in ano satisfying the inclusion and exclusion criteria were allocated to lateral sphincterotomy and segmental internal sphincterotomy groups. The outcome factors were perianal sepsis, pain relief using VAS as assessed on passing the first motion, duration of healing of fissure, assessment of incontinence using Wexner’s continence score on 30th post-operative day.Results: A total of 54 cases were enrolled, of them 31 patients underwent lateral internal sphincterotomy and 23 underwent segmental internal sphincterotomy with the mean age of patient was 34.76 years and a male to female ratio of 1.07:1. The pain score (VAS) on passing stool for the first time postoperatively was 4.5 with lateral sphincterotomy and 3.91 with segmental internal sphincterotomy which was statistically significant (P value &lt; 0.010). The duration of postoperative healing was observed to be 27.94 days and 28.09 days in lateral sphincterotomy and segmental internal sphincterotomy group respectively. The post-operative anal incontinence was evaluated by using Wexner’s continence grading after one month which was not statistically significant between two groups.Conclusions: Segmental internal sphincterotomy could be a good surgical modality with its healing effect on fissure in ano and post-operative complications which are similar to standard lateral internal sphincterotomy.

Introduction: Fistula in-ano or perianal fistula is a chronic abnormal communication which extends from anorectal lumen (internal opening) to external opening over the skin of perineum. Per-rectal examination is mandatory to assess the internal opening and also to assess the other associated conditions like anal fissure, hemorrhoids. The main principles of anal fistula surgery are to eliminate the fistula tract, prevent recurrence and preserve anal sphincter function. These surgical procedure Ligation of Intersphincteric fistula tract and Seton placement are being widely used to treat the perianal fistula or fistula in-ano. This research paper aims to compare the advantages and disadvantages between ligation of intersphincteric fistula tract versus Seton placement in treatment of perianal fistula. The study to evaluate parameters such as post-operative pain using VAS score, study to compare the patient's quality of life and other complications like fecal incontinence, recurrence and duration of hospital stay to determine most effective treatment method. Methodology: The study involves a comparative analysis of the patients undergoing Ligation of intersphinteric fistula tract and Seton procedure for treatment of Peri-anal fistula or fistula in ano with parameters such as post -operative pain using VAS score, post-operative quality of life and recurrence, fecal incontinence, Emotional health and Daily Physical activity of Patients. Result: The result indicate that both the procedure is safe in terms of fecal incontinence and recurrence and post-operative pain on Post-operative day 1 is more associated with LIFT procedure as compare to Seton. Post-operative discomfort is more with Seton placement and social activity limitation is slightly higher with Seton. Discussion: Currently fistulectomy, laser treatment, Ligation of inter-sphincteric fistula tract and Seton placement procedure is being performed frequently for the treatment of fistula in perianal fistula. current paper reports on comparision of these procedures LIFT and Seton are better in terms of fecal incontinence and recurrence for the treatment of fistula in ano. social activity limitation is slightly higher with Seton procedure as compare to LIFT procedure. Post-Operative pain on day one is more with LIFT as compare to Seton but pain on post-operative day-15 is slightly more with Seton as compare to LIFT procedure. Conclusion: In both the procedure recurrence rate is very low, there is no fecal incontinence with both procedures. There significant difference in postoperative pain on day one which is more with LIFT as compare to Seton placement. Social and emotional behavior is slightly more affected with Seton placement as compare to Ligation of inter-sphincteric fistula tract surgery.

Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6-8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointment t.i.d. or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire. Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (+/-1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0 vs. 41 percent; P = 0.0004) and were less likely to require subsequent surgical treatment (0 vs. 59 percent; P < 0.0001) than patients treated with nitroglycerin. Patients in the lateral internal sphincterotomy group were more likely to say that they were "very" or "moderately" satisfied with their treatment (100 vs. 56 percent; P = 0.04) and that they would choose the same treatment again (92 vs. 63 percent; P = 0.02) than patients in the nitroglycerin group. Finally, the fecal incontinence and fecal incontinence quality of life scores at six-year follow-up were similar in both groups. After six years of follow-up, it seems that lateral internal sphincterotomy is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence. Thus, sphincterotomy continues to be a good treatment for patients with chronic anal fissure.

BackgroundChronic anal fissure is a painful condition that can greatly affect quality of life. When conservative treatment fails, lateral internal anal sphincterotomy is performed to promote healing. The procedure may involve partial or complete sphincter division, which can influence the risk of fecal incontinence. This study aimed to compare the outcomes of tailoring the length of the lateral internal anal sphincter with either the whole length or the fissure apex and their effect on fecal continence in the treatment of chronic anal fissure.MethodsThis comparative, prospective, observational study included 40 adults with chronic anal fissures that did not improve with medical treatment. Patients were divided into two equal groups on the basis of the type of sphincterotomy performed: full-length sphincterotomy or sphincterotomy limited to the fissure apex. Patient details and postoperative outcomes were closely monitored, with follow-up visits conducted over 1 month to assess recovery and complications.ResultsThe present study revealed significant differences between the studied groups in terms of postoperative pain and bleeding occurrence (P < 0.001). Postoperative pain was significantly higher among patients who underwent complete sphincterotomy (70%) compared with those who underwent partial sphincterotomy (20%). Similarly, bleeding was significantly more common in the complete sphincterotomy group (55%) than in the partial sphincterotomy group (25%).ConclusionsPartial lateral internal anal sphincterotomy appears to offer a balance between fissure healing and continence preservation, making it a preferable option for patients at higher risk of incontinence.Trial registrationNot applicable.

Objective: To compare lateral internal sphincterotomy with injection Botulinum toxin for chronic anal fissure treatment in terms of improvement in mean postoperative pain, frequency of healing and fecal incontinence. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Rawalpindi, Pakistan, from Feb to Aug 2019. Methodology: Among the patients reporting to Surgical Unit II of Combined Military Hospital Rawalpindi, Pakistan. 80 individuals with chronic anal fissure, 12- 60 years of age were included in the study. Patients who have recurrent disease, fistula in ano, hemorrhoids, cardiovascular disease, and coagulopathies were excluded. Group-A patients had lateral anal sphincterotomy as an elective case under spinal anesthesia. Whereas Botulinum Toxin A was administered under local anesthesia in internal anal sphincter in Group-B patients in the outpatient department (OPD). Patients were followed up at 1, 4, 8, and 12 weeks in the OPD. Results: In Group-A, mean postoperative pain was found to be 3(4–2) in Group-A, and in Group-B was found to be 2( 2–1) with a significant p-value &lt;0.001. Healing of fissure was seen in 26(65.0%) in Group-A and 34(85.0%) in Group-B (p-value=0.039). Temporary fecal incontinence was seen in 16(40.0%) in Group-A and 05(12.50%) in Group-B (p-value =0.005) Conclusion: This study determined that in chronic anal fissure treatment, injection Botulinum toxin is superior to lateral internal sphincterotomy in postoperative pain, healing, and fecal incontinence.